GRMC Student Athlete Medical Authorzation Form

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Email address *

First name *

Last name *

Date of Birth *

Gender

Sport(s): *

Assumption of Risk

I realize that participation in athletics entails a risk of injury, and that I share responsibility for minimizing the risk of injury to myself and others. I must promptly report any injury I have suffered to my athletic trainers. I must give the athletic trainers and coaches a full honest understanding of my physical condition. I must advise my athletic trainers of any medications that I am taking.

I understand that I must report any problems in the condition or usefulness of equipment that I use. Finally, I know that it is important for me to listen to coaches’ instructions. I must try, as best as I can, to abide by instructions and guidelines relating safety, and to avoid injuries and accidents in my athletic activity.

Medical Consent

I hereby grant permission to Great River Medical Center’s Athletic Training Staff and Team Physicians/Consultants to render to my son or daughter, or to myself, any treatment or medical care deemed reasonably necessary. This includes preventive care, first aid, rehabilitation, treatment modalities and emergency treatment. Also, if deemed necessary, I grant permission for hospitalization.

Emergency Medical Authorization

We consent and authorize any authorized doctor, emergency technician, hospital, or other medical facility to treat or attempt to treat while he/she participates on a Great River Medical Center contracted team, or when traveling to or from or competing in any team activity. We further authorize any licensed physician to perform any procedure which he or she feels appropriate in attempting to treat or relieve any injuries or any related unhealthy conditions that may be encountered during any necessary procedure or operation. We further consent to the administration of any anesthesia given by any licensed physician, and do hereby further authorize any x-ray examination, medical or surgical diagnosis or treatment, and hospital care to be given to the participant in our absence under the general or special supervision and on the advise of a licensed physician, surgeon, anesthesiologist, dentist, or other qualified personnel acting under their supervision.

We realize and appreciate that there is a possibility of complication and unforeseen consequence in any medical treatment, and we assume any such risk on behalf of ourselves and that participant as stated herein. We acknowledge that there has been no warranty made as to the results of any such treatment or diagnostic procedure.

Each of the undersigned expressly acknowledge and agree that they have read and understand the terms of this forms, including the ASSUMPTION OF RISK, MEDICAL CONSENT, and EMERGENCY MEDICAL AUTORIZATION and further state that no oral representation, statements, or inducements apart from the foregoing written provisions have been made.

Medical History given in Athlete Connection

The undersigned, hereby:

1. Affirm that all answers and information are correct and true, and that no answers or information have been withheld.
2. Understand that his/her having passed the physician examination does not necessarily mean he/she is physically qualified to engage in athletics, but only that the examiner did not find any medical reason to disqualify him/her.
3. Fully realize that Great River Medical Center’s Athletic Training Staff cannot be held responsible for any previous medical condition(s) he/she might have.

Release Form Confirmation for Student-Athlete

I am submitting this form as a Student-Athlete and by clicking the below checkbox am confirming that I have read, understand, and voluntarilly sign this release form. *

I have read, understand, and voluntarilly sign this release form.

Student-Athlete Name *

Release Form Confirmation If Student-Athlete is Under 18

I am submitting this form as the PARENT or LEGAL GUARDIAN of a Student-Athlete under the age of 18 and by clicking the below checkbox am confirming that I have read, understand, and voluntarily sign this release form. *